Appointment Request Form

To request an appointment using this form:

  • Tell us the patient’s name, contact phone number and e-mail, preferred time(s) for an appointment, and basic reason for the visit.
  • When you’re done, click Send. If you make a mistake, please fill out the form again and resend, explaining in “Additional information.”

Patient's Name

Contact Phone Number

Contact Email

Select the Clinic
 Great West Family Care (insurance) New West Medical Care (insurance-free)

Select a Doctor
 Dr. Rebecca Hoffman (M, T, Th, F) Dr. Rusty Carroll (M, T, W, F) No preference

Preferred and alternate times and dates for the appointment
Office is open M-F, 8:30 am-5 pm (closed 12-1 pm)

Reason for the visit and any additional non-confidential information or questions

If you are a new patient, be sure to fill out the registration forms, too.